Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

An Ode To Hope, The Ultimate Medicine

AN ODE TO HOPE….THE ULTIMATE MEDICINE

I was recently made aware of a post written by a patient suffering from occipital neuralgia.  This disorder is a terribly debilitating neurological condition often characterized by unremitting pain in the back of the head and neck that, if left untreated, can lead to pain in the temples and face.  The gist of her essay was that at times, the burden of this chronic pain was so overwhelming that there was a desire to just ‘get off the train’ to make it stop.  I read this post with sadness and empathy and had been chewing on its message for the past several days.  I then began to reply with a message of hope which, in the case of ON, I believe is very real and possible.  Over the years, I have seen numerous patients who came to believe there was nothing anyone could do to help them.  These patients felt abandoned by their doctors who either didn’t understand their condition, didn’t care or simply didn’t know what to do despite the best of intentions.  In fact, despite beating the drum about the surgical treatment of ON, I continue to find that many physicians remain skeptical or simply unaware that a good treatment option exists.  Aside from the actual physical, emotional and psychological burden of the actual pain, this perceived state of affairs causes further trauma and often leads to outright despair on the part of the patient.  Yet somehow, through sheer grit and a desire to keep looking for solutions, they arrived at my office.  Happily, in the overwhelming majority of cases we found a path forward together - not always a cure, but a significant improvement in their daily pain that made their lives better and restored their belief that things would eventually be ok.  The fulfillment derived from the ability to give someone their lives back in this way cannot be put into words and is the reason doctors do what they do.  The take-home message was simply to never give up hope, to always look for answers, even if you had to look outside the box and to have the knowledge that a solution is always possible, just sometimes harder to find.

As I began to finalize this post, I heard from the husband of a former patient who, in the prime of her life had just passed away from an accident at home.  I had operated on her for ON almost 4 years to the day and happily, she had done very well.  There were other pain-related issues with which we were also able to help and the road to recovery was far from smooth, but her ability to stay positive and always look towards the future overpowered the years of suffering.  She was a true warrior and recently had essentially weaned off of all of her medication. She looked like a new person when I last saw her with a smile and brightness I hadn’t appreciated on her initial visits.  I can’t help but feel in my soul that what truly sustained and ultimately healed her was the love of her amazing & devoted husband and their children as well as her unending optimism.  After an initial emotional reaction, I called her husband to convey my condolences and provide whatever support I could, given the circumstances. We spoke for some time and he kindly allowed me to dedicate this post to her. 

Charlotte, this one is for you.  My faith teaches me that we don’t know what happens when we pass, but we can live on in the hearts and memories of those who remain with us.  I can think of no one who better epitomizes this message. Your life and example of never-ending optimism taught me so much, made me a better physician, and will continue to serve others whom I treat in the future when the world seems dark.  I’ll end with one of your favorite sayings: “You don’t have to move mountains. Simply fall in love with life.  Be a tornado of happiness, gratitude, and acceptance.  You will change the world just by being a warm, kind-hearted human being.” Charlotte, you have done just that.

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Dr. Peled Named Top Doctor By Castle Connolly

Dr. Peled Top Doctor

Dr. Ziv Peled has been named as a 2018 Top Doctor by Castle Connolly, one of the trusted names in the medical industry.  Dr. Peled earned the honor for his tireless work to make the lives of patients better, in plastic surgery and migraine surgery.  Dr. Ziv Peled's career is marked by hundreds of satisfied patients and multiple awards and articles written.

 

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THE INJURED NERVE – WHAT TO DO?

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One of the questions I find myself answering again and again is how I make the decision as to what to do with a nerve once I see it in the operating room. Do I perform a neurectomy and muscle implantation or do I stop at a decompression? There are a lot of factors that go into making that decision so I will elaborate on a few of these in the lines that follow.

To begin, there are certain ultrastructural characteristics that indicate a relatively healthy nerve. One, you should have an intact vasa nervorum – the blood vessels within the nerve. These can be seen under loupe magnification as fine red lines and indicate good blood flow to the nerve itself.   Blood flow is usually a sign of life and this nerve should be considered for decompression and preservation. Another characteristic is the feel of the nerve. A healthy nerve should feel like a soft, wet noodle. If a nerve is firm like a banjo string, it usually means that there is at least scarring of the epineurium (the outermost covering of the nerve) and often the structures contained within. In these cases, an internal neurolysis to separate the healthy from unhealthy fascicles is required and if the scarring affects too many fascicles, a neurectomy with muscle implantation is probably the better part of valor. Third, the fascicular pattern should be visible. Think of nerve fascicles like bundles of wire (e.g. the blue one vs the red one in all of those movies in which the hero is trying to defuse a bomb) within an electrical cord. Stated differently, what you’re looking at when you look at a cord plugged into a wall is a rubber tube - the actual wires are the copper fibers inside that rubber housing. Those copper wires are analogous to the individual neurons (i.e. nerve cells) and in an electrical wire, are often arranged into bundles. In a nerve, those bundles of neurons are called fascicles. However, unlike the cord plugged into the wall, in a healthy nerve, the “rubber housing” should be transparent and the fascicular pattern should be visible. If it isn’t, the nerve isn’t completely healthy and those fascicles may be permanently damaged. Take a look at the attached picture of a recent patient whose supraorbital nerve branches (multiple black lines) and supratrochlear nerve (arrowhead) are visualized. Notice how white the supratrochlear nerve towards the right of the picture is and the lack of any fascicular pattern. In contrast, the supraorbital nerve branches towards the left are pink indicating an intact vasa nervorum and the fascicular pattern is visible if you look very carefully (and likely magnify the picture on your computer). Fortunately for this patient, the vasa nervorum re-constituted and the fascicular pattern became more pronounced once the supratrochlear nerve was decompressed and a few minutes were given for the nerve to declare itself – yet another nuance of technique. Therefore, both nerves were able to be preserved in this particular case.

Yet another factor to consider when deciding what to do with a nerve in the operating room is the actual function of the nerve itself. For example, the greater occipital nerve, as its name suggests, has the largest area of sensory distribution of any nerve in the occipital region. Therefore, performing a greater occipital neurectomy would leave the patient with a relatively large area of numbness. Personally, I have a relatively high threshold for transecting the GON. By contrast, the third (a.k.a. least) occipital nerve is many times smaller than the GON and has a minimal area of sensory distribution that is often also supplied in a redundant fashion by the GON. Therefore, if the third occipital nerve is damaged, I have a lower threshold for performing a neurectomy since it is likely the patient wouldn’t have much numbness, if at all, were that nerve to be cut and buried in a muscle. Lastly, is what I would call the “x factor”, in other words clinical decision making. I’m often reminded of a saying I heard once that went something like this, “Good judgement comes from experience and experience comes from bad judgement”. In other words, experience counts and takes into account a myriad of other variables before ultimately making decision A versus decision B. What was the mechanism of injury and how long ago did it occur? What other treatments have they had that might have affected the nerve along its length (e.g. RFA or cryoablation) and how many times have those modalities been performed? How did the patient respond to the numbness from the nerve blocks? How old is the patient and how likely is it that they would tolerate a repeat procedure if decompression fails? Alternatively, how young is the patient and what is their regenerative potential? If you cut that young person’s nerve, how would they tolerate 50 years of numbness as opposed to the 70 year-old patient who may only live with it for a few years and has many other medical problems more pressing than a little hypoesthesia. The take home message is that electing to perform a neurectomy as opposed to a decompression involves a multifactorial decision making process so have a frank discussion with your surgeon about how s/he will decide which path to take.

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Dr. Peled Named to PRS Editorial Board!

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At the most recent Plastic and Reconstructive Surgery- Global Open (PRS Global Open) Managing Committee and Editorial Board meetings held in October 2017 in Orlando, Florida, I was nominated and elected as an Associate Editor to the Editorial Board of PRS Global Open. My nomination and election has been subsequently forwarded to the ASPS Executive Committee. They have approved my selection, and I am now an official member of the Editorial Board of PRS Global Open!

Read the whole statement here!

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LIONS AND TIGERS AND NEUROMAS….OH MY!

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Over the past few weeks I’ve had a number of people in the office tell me that they heard you should never cut a nerve because it would grow back and cause more pain. I have always been baffled by this comment since nerves can be repaired, reconstructed and dealt with much like blood vessels and bones. Obviously, there are differences in that, for example, you would never use plates and screws on a nerve like you would for a long bone (e.g. the femur – thigh bone). Moreover, if you think about it, what would happen to all of those poor souls whose nerves are injured and cut in accidents? Would they be doomed to a life of numbness and pain? Of course not. So let’s delve into this issue a bit more.

When a nerve has been permanently injured and a piece of that nerve must be removed, there are several options for repair. Ideally, a primary repair (i.e. putting the ends back together directly) would be performed, but this maneuver is only possible in certain specific situations such as when there has been a sharp cut (e.g. with a piece of glass), very little nerve is actually missing and relatively little time has elapsed from the injury to presentation. If a primary repair is not possible, there are other options including repair with nerve conduits, nerve grafts (both autologous [i.e. from the person themselves] or exogenous [e.g. cadaveric]) and perhaps even nerve transfers. Similarly, if a sensory nerve is transected and implanted into a muscle, the majority of patients do well albeit with possible numbness in the former nerve distribution. However, in some cases of nerve transection and implantation, just like in the cases of nerve repairs following injury, the procedure does not go as planned and numbness, loss of function and/or pain remains. In some of those cases a neuroma forms. So now what?

Well, one of the best things you learn as a plastic surgeon and one of the things that makes our training unique (admittedly I’m biased) is the ability to use surgical principles in creative ways. For example, you can learn all sorts of flap and graft techniques for facial reconstruction following removal of skin cancers, but if you really think about it, everyone’s face is different. Their skin quality, skin amounts, the location of the holes left by tumor removal, the orientation of those defects, the degree of exposed underlying structures are absolutely unique in every case. Therefore, the plastic surgeon must apply the principles s/he has learned and create a reconstructive plan that is similarly unique in each case. The same is true if a neuroma forms. As we noted above, there are several options for nerve injuries and those principles can be applied to the treatment of neuromas.

If a nerve was happily ensconced in a muscle, but was jarred loose by a subsequent accident, then that nerve end may simply be found, freshened and re-implanted further into a muscle. Another treatment option for a post-operative neuroma is to perform an end-to-side repair of that nerve to another sensory (or perhaps even motor) nerve. We do these types of re-innervation procedures to help amputees power the newer myoelectric/bionic prosthetics you may have seen on TV. Yet another option is to excise that neuroma and connect that new nerve ending to a long cadaveric nerve graft (i.e. an allograft). In this case, the surgeon would be utilizing the principle of distance in that it is unlikely the cut nerve would actually grow all the way through the entire graft and hence the end of the allograft would be quiescent and unlikely to cause further pain. So you see, there are almost always ways of dealing with issues that arise. In other words, a neuroma is not necessarily the end of the story.

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Dr. Ziv Peled To Speak at Plastic Surgery The Meeting 2017

PSTM17 website logo block L 2xPSTM17 website logo block L 2xDr. Ziv Peled will be speaking today at Plastic Surgery: The Meeting 2017 TODAY at the meeting in Orlando, Florida.  Dr. Peled will be discussing Migraine Surgery and its benefits to patients.  He will also help teach a cadaver course to teach his techniques for migraine surgery to other surgeons.

Migraine headaches have traditionally been thought to begin within the central nervous system (i.e. the brain and/or spinal cord) and then produce symptoms elsewhere such as throbbing in the back of the head, forehead or temples. There are many theories as to what exactly within the central nervous system is causing these chronic and often debilitating headaches. Some of these theories include pathologic blood vessel dilatation and constriction (loosening and tightening), abnormal firing of neurons within the brain, and abnormalities of various biologic substances (e.g. serotonin, calcitonin gene-related peptide). The fact that no one theory has been proven correct is likely one of the many reasons that there are so many different methods for the treatment of chronic headaches like migraines. In fact, from a medication standpoint alone, there are not only dozens of medications used to treat migraines, but dozens of classes of medications such as triptans, anti-depressants, muscle relaxants, blood pressure medications, narcotics, anesthetics, ergotamines, and so on. Fortunately, a different perspective on chronic headaches has produced remarkable results that have been previously unheard of.

This different school of thought suggests that peripheral nerve irritation (i.e. irritation of nerves outside of the brain and spinal cord such as those within the scalp or forehead) can cause irritation within the central nervous system thus leading to the perception of and symptoms of a headache. If this mechanism were in fact the culprit, then identifying and correcting the cause of such irritation could produce relief from the headache symptoms. Plastic surgeons have been doing exactly that with a common nerve irritation problem known as carpal tunnel syndrome. In this syndrome, a nerve within the wrist is compressed (i.e. pinched) and surgeons decompress (i.e. un-pinch) it thereby relieving the symptoms of pain with a greater than 90% success rate. Recent research has demonstrated that just like at the wrist, there are nerves within the head and neck that are compressed and that decompressing them, can produce significant or even complete relief that is permanent.

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The Little Things

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I received some great news yesterday. I was speaking with one of my patients discussing their current condition six months following her operation. Happily, she is doing quite well and has no more headaches except with severe barometric changes. She rarely requires any opiates except in those unusual situations which thankfully occur very infrequently. This patient does have a little are of sensitivity, but with a postage-stamp sized Lidoderm patch worn overnight, she sleeps well and is extremely happy; which makes me extremely happy. But this result is not the best part. As we spoke, I asked her about her plans to adopt a child, something we had discussed on many occasions in the past as it has been a goal of hers for quite some time.   She relayed that her status was “going to committee” later that day, when a group of people would decide whether this child would be adopted by her or one of two other families. A few hours later, she received great news - she was going to be a mom. I had a big fat grin on my face for several hours thereafter knowing how happy she was and what a great mom she was going to be. As a father of three, I can totally relate. During clinic in the afternoon, another patient came back several months following her operation. She and her husband had recently returned from a trip to Iceland which they told me they enjoyed more than any vacation in recent memory, in large part because she did not have any more headaches, something that had plagued her on many prior trips. When I first walked into the room, the smile on her face said it all. Still later that day, I also heard back from the mother of a third patient who is now 18 months following her operation. This woman told me that her daughter is now also a new mother! Moreover, she felt that her daughter would not have been doing the things she was doing at the present time were she to be in the same state she was prior to her operations, which her mother credits with helping her daughter achieve these milestones.

This is the good stuff. As physicians, we are often trained to be very clinical which is important and rewarding. After all, it feels good to something well. It can also be daunting hearing about how many people suffer, often for long periods of time without much relief. However, it is the human aspect of what we do that is truly gratifying and these challenges are also great opportunities. To see and feel that we can touch people’s lives in such meaningful ways, is difficult to put into words (despite this blog’s attempt at doing just that). Yesterday was a good day.

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Peripheral Nerve Surgery For Your Los Angeles Headaches

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Migraine headaches have traditionally been thought to begin within the central nervous system (i.e. the brain and/or spinal cord) and then produce symptoms elsewhere such as throbbing in the back of the head, forehead or temples. There are many theories as to what exactly within the central nervous system is causing these chronic and often debilitating headaches. Some of these theories include pathologic blood vessel dilatation and constriction (loosening and tightening), abnormal firing of neurons within the brain, and abnormalities of various biologic substances (e.g. serotonin, calcitonin gene-related peptide). The fact that no one theory has been proven correct is likely one of the many reasons that there are so many different methods for the treatment of chronic headaches like migraines. In fact, from a medication standpoint alone, there are not only dozens of medications used to treat migraines, but dozens of classes of medications such as triptans, anti-depressants, muscle relaxants, blood pressure medications, narcotics, anesthetics, ergotamines, and so on. Fortunately, a different perspective on chronic headaches has produced remarkable results that have been previously unheard of.

This different school of thought suggests that peripheral nerve irritation (i.e. irritation of nerves outside of the brain and spinal cord such as those within the scalp or forehead) can cause irritation within the central nervous system thus leading to the perception of and symptoms of a headache. If this mechanism were in fact the culprit, then identifying and correcting the cause of such irritation could produce relief from the headache symptoms. Plastic surgeons have been doing exactly that with a common nerve irritation problem known as carpal tunnel syndrome. In this syndrome, a nerve within the wrist is compressed (i.e. pinched) and surgeons decompress (i.e. un-pinch) it thereby relieving the symptoms of pain with a greater than 90% success rate. Recent research has demonstrated that just like at the wrist, there are nerves within the head and neck that are compressed and that decompressing them, can produce significant or even complete relief that can be permanent.

Peled Migraine Surgery of San Francisco has emerged as a leader in the development of peripheral nerve surgery as a migraine relief technique. Ziv M. Peled, MD* is a Board-Certified plastic surgeon trained to perform the full spectrum of aesthetic and reconstructive plastic surgical procedures. He completed his medical school training at the University of Connecticut School of Medicine where he earned honors in multiple surgical disciplines. He subsequently completed four years of rigorous general surgical training at the University of Connecticut during which he also completed an additional two-year, post-doctoral Basic Science Research Fellowship at Stanford University under the tutelage of Dr. Michael T. Longaker, a pioneer in the field of scarless wound healing. During that time, Dr. Peled not only helped establish Dr. Longaker’s laboratory at Stanford, but was also awarded a 5-year NIH grant for his work in keloid biology and scarless wound repair. Ziv then completed a prestigious and highly sought-after plastic surgical residency at Harvard University. While there, he was awarded an “Excellence in Teaching” award from the Harvard medical students. Dr. Peled continued to hone his specialty skills with an additional year of training in peripheral nerve surgery at the Dellon Institute for Peripheral Nerve and Plastic Surgery. He is Board-Certified by the American Board of Plastic Surgery, which means that he graduated from an accredited medical school, completed numerous years of residency training, and successfully passed a series of comprehensive written and oral examinations. The American Board of Plastic Surgery is one of only a select few specialty boards recognized by the American Board of Medical Specialties (ABMS) and is the only ABMS board which certifies candidates in the specialty of plastic surgery of the entire body. Dr. Peled is also a member of the California Society of Plastic Surgeons and the American Society of Peripheral Nerve PN) - the leading society of peripheral nerve surgeons.

In addition to his cosmetic and reconstructive work, Dr. Peled helped to found a perpiheral nerve surgery institute here in San Francisco. In that institute, he served as Director and Chief Plastic & Peripheral Nerve Surgeon. His specific training enables him to perform a unique set of surgical procedures designed specifically to restore sensation and minimize/eliminate pain in patients suffering from migraines as well as neuropathy due to diabetes, chemotherapy and thyroid disorders. He has also treated many patients with various forms of nerve trauma as well as many other types of nerve disorders. Dr. Peled has authored and co-authored over 40 manuscripts and book chapters on all aspects of plastic surgery and has presented his work at numerous national meetings. He has performed several hundred peripheral nerve procedures of various kinds. Ziv is an Active Member of the American Society of Plastic Surgeons and was also recently elected as a member of the American Society for Peripheral Nerve. This honor recognizes and highlights Dr. Peled's breadth of work with peripheral nerve patients suffering from migraines and diabetes as well as his published work on peripheral nerve surgery.

Visit http://peledmigrainesurgery.com today for more information, and to make an appointment to relieve your migraines.

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Los Angeles Headache Surgery

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Los Angeles is home to just under 4 million people. Since 18% of women and 6% of men suffer from debilitating migraines, this means that almost 720,000 women and 240,000 men suffer from the headaches. Where can these people turn to for treatment of migraines?

Up the coast in San Francisco, Dr. Ziv Peled specializes in migraine and headache surgery, giving Californians an opportunity for migraine relief. Dr. Peled uses peripheral nerve surgery to relieve the tension around the nerves that are causing the migraines.

Surgical decompression for chronic headaches is performed as an outpatient procedure at an accredited surgery center or in the outpatient department of the California Pacific Medical Center. The procedures can last anywhere from 1 hour to 3 hours depending on the number and locations of the nerves being treated. There are few restrictions following the procedure and discomfort is usually very well tolerated with oral pain medication. 

As an outpatient surgery, you can come to our San Francisco offices or we can perform the surgery at a center near you. You can be back home that night, well on your way to recovery from your migraines. Dr. Peled has performed hundreds of these procedures. Our testimonials page is filled with patients thanking Dr. Peled for changing their lives for the better.

If you are in Los Angeles, Rancho Palos Verdes, Pacific Palisades, Burbank, Alhambra, Carson, Glendale, Hawthorne, Inglewood, Lancaster, Pasadena, Pomona, Santa Clarita, Santa Monica, West Covina, or any of the surrounding areas and are suffering from migraines, we can help.

Call Dr. Peled today at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about how peripheral nerve surgery can help you with your headaches. Headache surgery in Los Angeles can be a phone call away.

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How Can Peripheral Nerve Surgery Help My Migraines?

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Migraine headaches have traditionally been thought to begin within the central nervous system (i.e. the brain and/or spinal cord) and then produce symptoms elsewhere such as throbbing in the back of the head, forehead or temples. There are many theories as to what exactly within the central nervous system is causing these chronic and often debilitating headaches. Some of these theories include pathologic blood vessel dilatation and constriction (loosening and tightening), abnormal firing of neurons within the brain, and abnormalities of various biologic substances (e.g. serotonin, calcitonin gene-related peptide). The fact that no one theory has been proven correct is likely one of the many reasons that there are so many different methods for the treatment of chronic headaches like migraines. In fact, from a medication standpoint alone, there are not only dozens of medications used to treat migraines, but dozens of classes of medications such as triptans, anti-depressants, muscle relaxants, blood pressure medications, narcotics, anesthetics, ergotamines, and so on. Fortunately, a different perspective on chronic headaches has produced remarkable results that have been previously unheard of.

This different school of thought suggests that peripheral nerve irritation (i.e. irritation of nerves outside of the brain and spinal cord such as those within the scalp or forehead) can cause irritation within the central nervous system thus leading to the perception of and symptoms of a headache. If this mechanism were in fact the culprit, then identifying and correcting the cause of such irritation could produce relief from the headache symptoms. Plastic surgeons have been doing exactly that with a common nerve irritation problem known as carpal tunnel syndrome. In this syndrome, a nerve within the wrist is compressed (i.e. pinched) and surgeons decompress (i.e. un-pinch) it thereby relieving the symptoms of pain with a greater than 90% success rate. Recent research has demonstrated that just like at the wrist, there are nerves within the head and neck that are compressed and that decompressing them, can produce significant or even complete relief that can be permanent.

Peled Migraine Surgery of San Francisco has emerged as a leader in the development of peripheral nerve surgery as a migraine relief technique.  Ziv M. Peled, MD* is a Board-Certified plastic surgeon trained to perform the full spectrum of aesthetic and reconstructive plastic surgical procedures. He completed his medical school training at the University of Connecticut School of Medicine where he earned honors in multiple surgical disciplines. He subsequently completed four years of rigorous general surgical training at the University of Connecticut during which he also completed an additional two-year, post-doctoral Basic Science Research Fellowship at Stanford University under the tutelage of Dr. Michael T. Longaker, a pioneer in the field of scarless wound healing. During that time, Dr. Peled not only helped establish Dr. Longaker’s laboratory at Stanford, but was also awarded a 5-year NIH grant for his work in keloid biology and scarless wound repair. Ziv then completed a prestigious and highly sought-after plastic surgical residency at Harvard University. While there, he was awarded an “Excellence in Teaching” award from the Harvard medical students. Dr. Peled continued to hone his specialty skills with an additional year of training in peripheral nerve surgery at the Dellon Institute for Peripheral Nerve and Plastic Surgery. He is Board-Certified by the American Board of Plastic Surgery, which means that he graduated from an accredited medical school, completed numerous years of residency training, and successfully passed a series of comprehensive written and oral examinations. The American Board of Plastic Surgery is one of only a select few specialty boards recognized by the American Board of Medical Specialties (ABMS) and is the only ABMS board which certifies candidates in the specialty of plastic surgery of the entire body. Dr. Peled is also a member of the California Society of Plastic Surgeons and the American Society of Peripheral Nerve PN) - the leading society of peripheral nerve surgeons.

In addition to his cosmetic and reconstructive work, Dr. Peled helped to found a perpiheral nerve surgery institute here in San Francisco. In that institute, he served as Director and Chief Plastic & Peripheral Nerve Surgeon. His specific training enables him to perform a unique set of surgical procedures designed specifically to restore sensation and minimize/eliminate pain in patients suffering from migraines as well as neuropathy due to diabetes, chemotherapy and thyroid disorders.  He has also treated many patients with various forms of nerve trauma as well as many other types of nerve disorders. Dr. Peled has authored and co-authored over 40 manuscripts and book chapters on all aspects of plastic surgery and has presented his work at numerous national meetings. He has performed several hundred peripheral nerve procedures of various kinds.  Ziv is an Active Member of the American Society of Plastic Surgeons and was also recently elected as a member of the American Society for Peripheral Nerve. This honor recognizes and highlights Dr. Peled's breadth of work with peripheral nerve patients suffering from migraines and diabetes as well as his published work on peripheral nerve surgery.

Visit http://peledmigrainesurgery.com today for more information, and to make an appointment to relieve your migraines.  

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How Many Headaches Is Too Many

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Over the past year or so, I've noticed that many patients are being told by their other treating headache doctors that they shouldn't consider surgery for their problem because their headaches are not bad enough. Patients are often so struck by these remarks that many wonder whether this statement represents actual medical fact and repeat it to me as if it were empirically true. They then ask me if I agree with that concept. My answer is always the same, the only person who can say whether the pain you're having is too much, is YOU.
Pain by definition is a subjective experience. There is no objective way to measure it such as with a blood test or an MRI. This fact represents one of the biggest challenges in treating people with pain. Moreover, what I've gleaned is that it's not only the actual episodes of pain that often constitute the greatest burden to people. Many times it is the constant lifestyle adjustments and manipulations often required to stave off the onset of pain that are the most difficult for people to manage. Patients often have to avoid social situations they'd like to be in, avoid foods they love to eat, and avoid activities they used to love participating in. To add insult to injury, I've also been informed by patients that their other headache doctors told them that they would terminate them as patients if they undergo surgical decompression.
I find such statements quite sad because they often leave patients very conflicted perhaps due to the fact that this other doctor has provided some measure of relief that they are afraid they will lose if they pursue other options. It also goes against my general opinion of how chronic headache pain (and all chronic pain for that matter) should be managed. I believe that a multi-modality approach that yields the best results. Just like in breast cancer treatment during which a patient often has surgery to remove the cancer with a breast surgeon, chemotherapy/hormone therapy with a medical oncologist and radiation treatment with a radiation oncologist. Only when these physicians work together do patients derive the optimal benefit.
Who then is anyone else to say how much any individual person should suffer? I believe that the role of the physician in these cases should be to establish a diagnosis if possible and formulate a treatment plan to address the pathology in question if possible often in combination with other clinicians. The physician should then educate the patient about his/her diagnosis and the possible treatment options. Patients must then decide for themselves based upon an evaluation of the potential risks and benefits of the proposed treatments which treatment options are best for them. The take home message - don't let anyone else make a value judgment for you. They can't.

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Hurry Up and Wait...

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I saw an interesting question posted today – something to the effect of, ‘If you have nerve decompression and/or transection, shouldn’t you feel immediate relief?” This question is a very important one, but the answer may not be intuitively obvious. The nervous system is truly complex and often quite difficult even for medical professionals to understand. Therefore, in an effort to explain why it can often take many months before a patient experiences the hoped for improvement, I’ll use an analogy to which many people can hopefully relate.

Most everyone has at some point, had the experience of falling asleep on their arm and waking up with slightly numb fingers. Upon waking, you notice the altered sensation in the fingers, shake them out and within a few seconds, sensation returns to normal. Many people have also had the experience of waking up after having fallen asleep on their arm for a longer time, getting up and realizing that they not only have very numb fingers, but also that they have difficulty moving their elbow, wrist and/or fingers very well. “Oh my gosh, did I just have a stroke?!?”, often comes to mind. In this scenario, you try to shake out the arm as best you can and it often takes a few minutes before things start to move again and sensation returns to the digits. Moreover, once the blood starts flowing again and sensation begins to recover, there is often a period of hypersensitivity before things settle down.

The difference in these two scenarios is the degree of pressure and the duration of pressure on the nerves in the upper extremity, obviously worse in the second scenario. Given the overall greater amount of pressure in this second scenario where you’ve probably slept on your arm for a few hours, it takes longer for the nerves to recover. Now take this second scenario and stretch it out much longer. In other words, let’s assume you’ve had pressure on your upper extremity for several years? Would the nerves be expected to recover in a few hours or days following decompression? Given what we know from the above examples, the answer is, ‘Probably not’. Recovery in these cases can take many months. The situation with neurectomy is a little bit different in mechanism, but the same in practicality. When you transect a nerve proximal (i.e. upstream) from an injured segment, you now have a “live” nerve end that you bury within the local muscle. However, doing so is not the same as turning off a fuse to an outlet with a short where the sparks stop immediately. Remember that this nerve is still attached to the spinal cord and therefore the brain, so impulses will still travel back and forth to that “live” end. However, with time, that sensory nerve end will likely make connections with other motor nerves within the muscle and in effect this “fools” that sensory nerve into thinking that it has found its downstream counterpart. You now have a sensory nerve connected to a motor nerve, a situation in which the impulses travel as they normally would, but have no effect on the muscle since the muscle only responds to motor nerve impulses. It would be like me having written this post in Sanskrit (which hopefully nobody reading this post understands). You might recognize it as writing, but it would make no sense and therefore would elicit no reaction. That being said, this process takes time which is the reason that relief following neurectomy with muscle implantation is often not immediate. The take home message is that recovery from any nerve operation is a process, not a moment in time. Hopefully that helps.

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Too Much Motion

neck pain migraine headacheI was asked by a member of this forum to comment on the concept of atlantoaxial instability (AAI) and how it might relate to symptoms of ON. This is an interesting question, but one that is important as it has relevance for patients with a number of clinical conditions such as Ehlers-Danlos Syndrome (EDS – which is not known to be associated with AAI) or those with rheumatoid arthritis (RA – which has been associated with AAI). I also promise to try to minimize the alphabet soup of abbreviations in an effort to avoid confusion.

First of all, what is AAI? Briefly, AAI results from osseous or ligamentous pathology between the two cranial-most vertebrae (spinal column bones) – the atlas (i.e. C1) and the axis (i.e. C2). This instability can result in too much or abnormal movement between the bones and soft tissues surrounding these two structures. AAI can happen secondary to a traumatic event, degeneration due to an infectious or inflammatory insult (e.g. rheumatoid arthritis) and/or a congenital abnormality such as Down Syndrome. When there is excessive or unusual movement of the atlas on the axis a number of problems can occur. The vertebrae can impinge directly on the spinal cord thereby resulting in neurologic manifestations. Compression of the nerve roots as they emerge from the spinal column in also a possibility as is neural pathology more peripherally as will be mentioned below. The good news is that AAI is quite uncommon in patients without any pre-disposing factors.

While the most common presenting symptom is non-descript neck discomfort and/or headache, these symptoms are quite non-specific. Appropriate imaging along with neurosurgical evaluation if pathology is discovered in patients, especially those who have predisposing risk factors are therefore warranted. Fortunately, almost all of the patients I see in my practice have already these evaluations and have come up without a diagnosis of AAI and remain unclear as to the cause of their pain. So how does any of this information relate to ON?

Well, as you can imagine, if you have abnormal or excessive motion at the bony level, it may result in undue traction on the overlying soft tissues which can certainly include the peripheral nerves. As I’ve mentioned in a previous blog post about whiplash and occipital neuralgia about two years ago, (http://peledmigrainesurgery.com/blog/entry/whiplash-and-occipital-neuralgia-what-s-the-connection.html) traction on peripheral nerves can lead to microscopic and in some cases macroscopic tears of the nerve itself which, in turn, can result in outright neuroma formation or cause scarring around the nerve. This scarring that can result in mechanical neural compression or limitation of motion and further traction injury. Similarly, in EDS, the same excessive motion can result from overall laxity in ligamentous structures. Please keep in mind that I am not a neurosurgeon or an orthopedic spine surgeon and this blog post should not take the place of a trained neurology, ortho spine or neurosurgical evaluation. That being said, from what little I’ve read and do know, the take home message is that when you have neck pain and/or headaches, it is unlikely to be AAI in most patients. As always, a good work up and exclusion of other causative factors is important, but if despite that, everyone is left scratching their heads, ON may just be the culprit.

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Why Did I Get Occipital Neuralgia?

Why Did I Get Occipital Neuralgia?

The title of this post is really the $60,000 question. I have posted many times in the past about how Occipital Neuralgia can be caused by compression from spastic neck muscles, compression by tight connective tissue (i.e. fascia) and/or compression from surrounding blood vessels. Many of the patients I see have had headaches ever since they can remember. However, there are just as many for whom the headaches began seemingly spontaneously one day. The question for these folks remains: What happened? Why now?

There have been recent articles that hint at possible answers to these questions and they may surprise you. I have attached a link to one of the more interesting ones as part of this post. One of the most surprising comments contained therein was that craning the neck downward only 60º puts as much as 60 pounds of pressure on the cervical spine and neck muscles. With that kind of pressure, you can imagine that nerves (among other structures) would be compressed. So the explanation as to why you might all of a sudden develop ON can almost be summed up in one word - overuse. This explanation is one of the potential causes of carpal tunnel syndrome, the most common compression neuropathy recognized (even by neurologists). Why could that not be the case for ON. Nerves are very susceptible to chronic compression (see post - ‘What Causes Occipital Nerves to Malfunction’) even if intermittent. The occipital nerves take very circuitous routes through all of the nuchal soft tissues. When you add to that fact the constant motion of our necks that require the nerves to glide constantly and then compound those factors with an additional 60 pounds of added pressure, there are many things that may occur to those nerves.

One, they may simply get kinked as they make their way through the neck to the scalp. Not a week goes by when I don’t see a patient in the office who, in describing their headaches contorts their head to recapitulate their symptoms and when they get it just right, it’s like a thunderbolt of pain. Two, even if not kinked, the pressure will compress the vasa nervorum - the microscopic blood vessels within the nerves themselves that supply blood to those nerves. After numerous episodes of compression, especially if for prolonged periods, these blood vessels can clot and the nerves become ischemic (i.e. choked). The neurons that comprise that nerve then die off and try to regenerate causing the hyperesthetic symptoms so typical of ON. Three, even if the nerves recover from each successive insult, the additive microtrauma will likely result in some inflammation and the subsequent formation of scar tissue in the surrounding structures, thus closing off already tight corridors through which these nerves must pass - another compressive force. While no one has demonstrated these possibilities in real time, I see the sequelae of them in the OR weekly.

So what to do we do? Good posture, stretching and avoidance of triggering activities seem to make common sense. In addition, as many of you know and as intimated in the article, steroids seem to be the mainstay of treatment amongst some practitioners, but as also stated, the effects are often not permanent. The reason is obvious - the compressive forces remain, even if inflammation is temporarily suppressed. Therefore, I continue to believe that decompression (or neurectomy & implantation for permanently injured nerves) are reasonable options as they are safe and effective. Moreover, they address the underlying problem, the mechanical compression of these poor nerves caused by our ever more technologically demanding lifestyles. So next time you pick up your smartphone, remember to pick up your head as well.  

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Dr Peled on Tri-County News on Headaches and Migraine Surgery

Dr. Peled appeared on Tri-County news to discuss migraine surgery and how it can help people with their chronic headaches and migraine pain.

Dr. Peled covers the definition of migraines, signs that you have a migraine, and ways to deal with the pain along with the surgical options. 

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BOTULINUM TOXIN AND HEADACHES

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Botulinum toxin has been used for quite some time to manage chronic migraines, specifically as a preventative agent. Like any treatment modality, the possibility for variable results exists. Certainly some people have had great results with treatment, but many have not. Very recently people have asked what their results with this treatment modality mean. Unfortunately, the answer is not straightforward for a number of reasons that I will delineate below.   Please keep in mind that these thoughts/opinions are general comments and not meant to be interpreted as specific to any particular patient’s situation. You will have to have a discussion with your treating physician as to how to interpret your specific results.

Botlinum toxin is most commonly used according to what’s known as the PREEMPT protocol. Briefly, this protocol calls for 31 injections for a total of approximately 155 units of botulinum toxin with some modifications allowed at the discretion of the treating physician. The PREEMPT protocol has been discussed in a number of journal articles, including a major article published back in 2010 in the journal Headache. In this study, patients were given either injections of botulinum toxin or placebo (both patients and physicians were blinded as to what was being given) and then followed for a total of 24 weeks. Botlinum toxin was injected at time 0 and again at 12 weeks with the final endpoint metrics assessed at 24 weeks. The authors demonstrate statistically significant differences in migraine and headache frequency (among other metrics) during the treatment period, in those patients receiving botulinum toxin as compared with placebo-treated patients. They conclude that botulinum toxin is a useful treatment modality for prevention of migraine headaches. So why doesn’t everyone use it? In my opinion, I believe there are a couple of very relevant criticisms of this study and the conclusions you can draw from it.

First, while clearly disclosed on the title page, the authors of this study are either employees of, have received research dollars from, or are paid consultants for the company that makes the specific form of botulinum toxin used; certainly a potential a conflict of interest although one that doesn’t necessarily invalidate the data presented. Second, while the data are somewhat obtuse and I am certainly no mathematician, if my calculations are correct (and I have redone them several times just to check) the patients in the Botox arm of the study had about 5 fewer headache days in about 6 months compared with those that were injected with placebo. If I told you as a patient that I would poke you with a needle 62 times over two visits and that if you were lucky and responded, you would have 5 fewer headache days in 6 months, would that be worth it? Perhaps and it’s better than nothing, but this result is hardly the wow factor many clinicians make it out to be. Second, let’s play devil’s advocate and say that a huge number of Botox patients had a complete response and had no headaches for the entire 24 weeks. My question to them would be: ‘Which of the 31 injections you got in each round was responsible for the great results?’ The answer would be impossible to give because botulinum toxin doesn’t work right away (it takes several days to become effective) and you got all 31 injections at the same time. So do you really need 31 injections or just 21, or perhaps just 5? You would have no idea. Third and going along with this line of thinking, if you had a great result with Botox, the presumption would be that you would need to continue with this type of therapy in perpetuity - not such a great proposition if you’ve got 40 years of injections to look forward to. I have also wondered what would happen to the neck muscles if they were constantly relaxed by botulinum toxin. Would they atrophy and weaken over time and if so, how would that affect your posture and your ability to lift your head? I don’t know the answer, but I would not want to find out on myself. The take home message is that you should have an open and honest discussion with your treating clinician about what you/they hope to accomplish with the results of any treatment you select along with the potential risks and benefits. Hope that helps.

For more information on headaches and headache relief, visit www.peledmigrainesurgery.com or call 415-751-0583 to make an appointment.

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THE TEAM APPROACH

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This post is a rather long one, but an important one nonetheless in my humble opinion. Over the years that I have been performing headache surgery, I have heard from so many patients that they are frustrated with their current treating physicians because their symptoms are not under control to the degree that they would like. Anyone who has been on these forums for a few hours has certainly run into a post or several posts describing a bad patient-physician interaction or a bad patient-health system interaction. To all of those people - I completely empathize and you have every right to feel as you do. Having been a patient on several occasions myself, I know what it’s like to speak with a physician or an insurance adjustor and feel like you are talking to the clouds. It is very frustrating and can often leave you feeling helpless – and I’m a surgeon. As a peripheral nerve surgeon, especially one that operates on people with chronic, intractable headaches, I have often heard criticisms from other practitioners whom I don’t feel even understand what it is that I do. However, in those situations I often find myself trying to put myself into the shoes of the doctor across from me. What I have found is that there is always common ground to be had somewhere and that understanding their perspective can help me find it. In addition, since we are (or should be) on the same side, I have found that viewing things from a team perspective is particularly and practically very helpful.

Breast cancer is sadly a disease that touches too many people throughout the world. Over the past few decades, the medical profession has made incredible strides in fighting this dreaded disease and we now have cancer remission rates that were once thought impossible. One of the biggest factors in helping this development along has been the team approach. In our community, a patient with a new breast cancer diagnosis is immediately given a team of physicians and clinicians to help them navigate the process that is dealing with this pathology. To be sure, there is a “captain of the ship”, usually the breast surgeon or oncoplastic surgeon who is coordinating all of the moving parts, but every member of the team is critical to ensuring success. While the breast surgeon may remove the cancer physically, there is often a plastic surgeon to help reconstruct the resultant defect, a radiation oncologist who will help ensure that any disease that might have spread locally is controlled and a medical oncologist who will determine if the risk of distant disease is high enough to warrant a regimen of chemotherapy or hormonal therapy, There is also often a psychologist and nurse navigator who can help the patient deal emotionally and psychologically with the fear often accompanying a cancer diagnosis. Only when you put all of these components together, do you get the wonderful results that modern medicine has been able to achieve.   If you think about it, the same team principles apply to a football team (American football as well as soccer), a dance troupe or a team of scientists working to find a cure for something. So what the heck does this diatribe have to do with headache surgery?

Well, for years I have been saying to my patients that hopefully someday soon, we will realize that chronic pain should be best treated with a multi-modality approach as with breast cancer. Chronic headaches are a form of chronic pain. There are certainly many patients for whom medical management works very well. Those people do not need any injections or surgical intervention. There are those for whom pharmacologic agents are simply ineffective and in those cases, nerve decompression may be a good option. However, for most, a combination of therapies is necessary to control the underlying symptoms. I have heard from countless patients who tell me that prior to surgery their medication (say Imitrex) was inconsistently helpful. “I could flip a coin” they would tell me, take it early in the middle or late in a headache attack, but they could never figure out why sometimes it was effective and sometimes not. Following surgery, their headache attacks are much less frequent and often much less severe, but what was interesting to me was that they would tell me that when they would get an attack, the Imitrex was almost always effective. “Why is that?” they would ask. Well….it is likely that they have two problems contributing to their headache symptom complex. One is a chemical imbalance that medication would treat, and the other is a mechanical compression of the nerve(s). Pre-operatively, when you had a headache, you reached for what you had which was Imitrex, but if it was the mechanical compression that was irritating the nerve that day, you didn’t get any better. If it was the chemical imbalance aggravating the nerve, you did get better. Post-operatively, the mechanical compression has been relieved so the headache frequency and severity are much less, but there are still headaches. However, now when you take the Imitrex, lo and behold it almost always works, because it is actually treating the underlying chemical imbalance that is causing those residual symptoms. The take home message is that patients still often need to have those pain management physicians and neurologists involved to manage those medicines so that their symptoms remain under optimal control. Those that have seen me know that I often like to communicate with the very same such doctors prior to surgery to ensure we can optimize the post-operative recovery period which certainly can have its share of ups and downs. In the end, we all have to partner in this endeavor together as a team.

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CHRONIC PAIN AND THE OPIOID EPIDEMIC, PART I

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I was recently invited to attend a meeting on the use of multimodality therapy to decrease the use of opioids in the US population.  Unless you’ve been away on a remote island for a long time or completely eschew any sort of media including newspapers and TV, you’ve probably heard that we have a problem with opioid use in this country.  I knew the numbers were bad, but frankly I came away from this meeting completely floored. Here are some statistics that should make you pause and take notice:

1. Americans account for only 4.6% of the world’s population yet have been consuming 80% of the world’s opioid supply and 99% of the world’s hydrocodone supply. 

Pain Physician. 2012; 15(3 suppl):ES9-ES38.

2. 1 in 15 patients will become chronic opioid users after surgery. 

Carroll I, et al, A pilot study of the determinants of longitudinal opioid use after surgery. Anesth Analg. 2102; 115(3): 694-702.  NIH, National Institute on Drug Abuse. Prescription and over-the-counter medications. Drug Facts. Revised Nov 2015. http://www.drugabuse.gov/publications/drugfacts/prescription-over-the-countermedications. Accessed 08/24/16.

3. 1 year following elective cervical spine surgery, approximately 1/3 of all patients were still using opioids.  

Wang M, et al. Predictors of 12-month opioid use after elective cervical spine surgery for degenerative changes [abstract]. Spine. 2103; 13(suppl): S6-S7.

4. 3 out of 4 people who misuse prescription painkillers,use medication that had been prescribed for someone else. 

Manchikanti L, et al. Opioid epidemic in the United States. Pain Physician. 2012; 15(3 suppl): ES9-ES38.  Office of National Drug Control Policy. 2013 Drug overdose mortality data announced: prescription opioid deaths level; heroin-related deaths rise[press release]. 01/12/15. http://www.whitehouse.gov/ondcp/news-releases/2013-mortality-data. Accessed 08/24/16.

5. Abuse of prescription painkillers like Oxycontin and Vicodinleads to eventual heroin use in 14% of people.

Busch S, et al. Abuse of prescription medication risks heroin use. Infographic created for: National Institute on Drug Abuse. http://www.drugabuse.gov/related-topics/trends-statistics/infographics/abuse-prescription-pain-medication-risks-heroin-useAccessed 08/24/16.

6. In 2012, 259 million prescriptions were written for opioids in the US. This number represents enough narcotics so that every American could have a full bottle of pills sufficient to take 5 mg of hydrocodone every 6 hours for 45 days.

7. The problem is obviously worse in some parts of this country than others.  For example, 1 in 6 PEOPLE (not patients, people!) in the state of Tennessee are on opioids. (Presentation at this meeting)

Obviously, given the scope of the problem, you might suspect that there is no one or easy answer and you would be correct.  There is plenty of blame to go around on all sides of this major issue, but that also means there may be many avenues from which to address the problem. The people in the conference today are at the forefront of this epidemic and have a number of interesting ideas and strategies as to how to begin to tackle this problem.  Stay tuned….

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The Headache Pain Caused by the Common Cold

The Headache Pain Caused by the Common Cold

An interesting thought occurred to me the other day as I was finishing up a particular headache surgical procedure.   Something that has come up over the years is that patients tell me that their headaches are worse when they are sick with the cold, flu or some other such issue. I have been pondering why this symptom change might be taking place for a long time. As with many of my blog posts, there are several possible causes for this phenomenon in my opinion and so I have decided to delineate these possibilities below.

One reason is that people who are sick are often more stressed either because of or as a cause of their illness. It is considered reasonable that stress, of whatever type, can weaken the immune system and thus mitigate the body’s ability to fight various pathogens. These pathogens can cause all manner of irritation and inflammation in various tissues such as muscles hence the muscle discomfort with the flu, for example. If one type of tissue is irritated, the surrounding tissues might suffer the same fate. In addition, when we are stressed, our blood pressure often rises. Since many of the nerves which we address during our operations are compressed by surrounding blood vessels, it follows that when these vessels beat harder (i.e. during a period of relative hypertension) the nerves which are already irritated may become even more so. But another, third thing happens during an infectious scenario, one to which most people can also relate. Have you ever felt your neck when you feel you have a sore throat or the sniffles? If so, you have probably noticed that the lymph nodes in the area are swollen and often tender. That is because these lymph nodes are the factories for pathogen-fighting cells and they ramp up production (hence swell) when you are sick. As I was dissecting this person’s greater occipital and lesser occipital nerves, I noticed several enlarged lymph nodes located within the already crowded spaces through which these nerves passed. Bear in mind that we don’t operate on people who are sick so these nodes were particularly enlarged given that fact alone. The nodes were further compressing these poor nerves which were already pressured by the surrounding blood vessels and scarred connective tissue. I could only imagine what occurs to these nerves if that person were to contract the flu. Those nodes would surely swell, sometimes quite dramatically and place even further pressure in the area causing even further pain. With pain comes higher blood pressure, hence more compression and so begins the upward spiral. One recurring question from patients is, “What is compressing my nerves?” The answer used to be possibly spastic muscle, tight/scarred connective tissue, enlarged or aberrant blood vessels. It now also includes abnormally large and/or poorly localized lymph nodes. Happily these nodes can be removed carefully and selectively to further relieve pressure during a decompression procedure and many of the patients in whom this lymph node removal was necessary have gone on to do quite well. Finally, none of the nodes which I have biopsied to date have revealed any evidence for malignancy or other pathology, further happily capping a saga that has resulted in many positive outcomes.

So if you suffer from headaches, please visit us at www.peledmigrainesurgery.com or call us at 415-751-0583 and 925-933-5700 to setup an appointment to find out if we can reduce or eliminate your migraines. We look forward to hearing from you!

 

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California Headache Surgery With Dr. Ziv Peled

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Surgery for chronic headaches in California is here.  People often call me from cities outside of San Francisco wondering if we can help them.  Happily, many times if they need it, I can help them, no matter where they come from! We have seen patients from all across the United States, and as far away as Brazil, New Zealand and Finland. Since chronic headaches occur in every part of the world, we are excited to help people in even further-flung areas and want to extend an invitation to everyone in California and abroad that we may be able to help reduce or eliminate their “migraines”with peripheral nerve surgery.

I have successfully performed many of these operations using my knowledge and experience in peripheral nerve surgery to ease the pain caused by compressed, irritated or injured nerves in the head that can lead to the excruciating “migraines” that people have been forced to live with for many years. My practice has developed a system to help with travel and lodging  and to ensure that each patient has as seamless an experience as possible.  We have also developed protocols utilizing Skype to confer with patients to discuss the potential for these often life-changing procedures. 

I also firmly believe that care doesn’t end with the surgical procedure. Of course, we do everything we can to ensure that the operation itself is successful, but continue a dialogue with patients often lasting many months following their procedures. While we ourselves cannot be everywhere, the ability to speak with and interact with your surgeon is important to deal with any issues that might arise during the post-operative and recovery phases. While these times can be challenging, our practice has refined the process to ask the right questions and determine if any further action is needed.  With Peled Plastic surgery, you won't be left on your own after your operation.

So if you suffer from chronic headaches or “migraines”, please visit us at www.peledmigrainesurgery.com or call us at 415-751-0583 and 925-933-5700 to set up an appointment to find out if we can reduce or eliminate your symptoms. We look forward to hearing from you!

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